Adult Social Care Record (MODS): Adult Social Care Record (MODS) Implementation Guidance

An individual's daily care involves a diverse group of healthcare and social care practitioners—including GPs, district nurses, social workers, care providers, care workers, social prescribers, local authority call handlers, among others. While these care workers do not function as a unified multi-disciplinary team, they require access to comprehensible and precise records. These records must be articulated in a vernacular that merges clinical precision with everyday language, enabling these varied practitioners to document and exchange information effectively. This collaborative approach is essential to inform continued care and support the individual in leading their desired lifestyle.

Scenario:

Mrs Smith (Subject of care) lives alone (Household composition) but due to mobility issues (Needs) she is unable to leave her home without support (Need) and requires assistance with dressing (Need) and personal care (Need). She has dementia (Need) so can give inconsistent responses regarding her abilities and medication (Risk). Jane (Care worker), an experienced care worker, visits (Tasks) Mrs Smith (Subject of care) at 10am. When she arrives she wakes (Action) Mrs Smith (Subject of care) and administers her medication (Medication, Action). Mrs Smith (Subject of care) complains of a headache (Problem) so additional medication is given (Medication, Action). Mrs Smith (Subject of care) is supported to get out of bed (Action) , shower (Action) and get dressed (Action). Jane cooks her breakfast (Action) and then leaves. At midday, Alan (Care worker), a new social worker, visits to review (Review) Mrs Smith's care plan (Care and support plan). Mrs Smith's son, Robert (Personal contact), also arrives to take part in this meeting. During the meeting Mrs Smith (Subject of care) says that she has no mobility issues and can use the toilet independently. Robert (Personal contact), challenges this and explains that Mrs Smith (Subject of care) has carers twice a day to help with this. Mrs Smith (Subject of care) is confused about her care needs and insists that she does not need support (Risk). She also asks for additional medication for a headache. Robert gives her this medication (Medication, Action). Sophie (Care worker), a new care worker who has recently joined the agency, arrives to visit (Tasks) Mrs Smith (Subject of care) in the evening. When she arrives Mrs Smith (Subject of care) advises that she does not need any help going to the toilet and has already taken her medication. Mrs Smith (Subject of care) insists that she does not need support so attempts to get to the bathroom by herself and falls (Incident). Sophie (Care worker) calls an Ambulance as Mrs Smith (Subject of care) hits her head when falling and she is taken to A&E (Admission details). Sophie (Care worker) is unsure what medication (Medication) Mrs Smith has taken today and the details of her support needs (Need, Risk) . When Mrs Smith (Subject of care) arrives at A&E she tells the doctor and nurses that she lives independently and does not need support with personal care. She also tells them that she has not taken any medication today. Goal: Support Mrs Smith to continue to live in her own home by providing consistent care and support. Sharing information with all other professionals and family carers to safeguard and support her, including preventing falls and monitoring medication administered.

Assumptions:

In this use case, the recipient of care lives alone but has dementia so may give inconsistent responses about her care and support needs and medication. Providing clear and consistent information/records about medication administered, Mrs Smith's mobility and personal care needs and the likelihood of confusion due to dementia is essential. This information should be shared with all professionals and family members regularly so they can support Mrs Smith appropriately. If this information is not available to all professionals supporting Mrs Smith, then she may injure herself, receive duplicate medication or overstate her abilities.

Process breakdown

Record the time Mrs Smith was woken (Action) Record the time Mrs Smith took routine medication (Medication, Action) Record the additional medication administered (Medication, Action) Record support required for personal care (Care and support plan) Record food provided (Action) Record Risks that Mrs Smith get’s confused and sometimes forgets that medication has been administered and overstates her abilities (Risk) Record fall and procedure followed (Incident). Record Hospital admission details (Admission details) Record Hospital records of medication administered and support required (Medication, Action)